Department of Veterans Affairs Network Policy No.: VA Desert Pacific Healthcare Network (VISN 22) Date: September 23, 2014 Long Beach, CA

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1 Department of Veterans Affairs Network Policy No.: VA Desert Pacific Healthcare Network (VISN 22) Date: September 23, 2014 Long Beach, CA CHRONIC OPIOID USE FOR NON-MALIGNANT PAIN 1. PURPOSE: To establish guidance for safe and effective use of opioids in the management of chronic non-malignant pain. 1. BACKGROUND: A n increase in opioid prescribing over the past ten years has resulted in significant increases in overdose deaths, treatment admissions, ED visits for misuse or abuse, dependency, nonmedical users, and diversion. The risk of opioid overdose has increased among VA patients, the risk rising with increased daily dose. 2. POLICY: Safe and effective management of pain in the care of Veterans is a priority for the Veterans Health Administration. In particular VHA seeks to reduce harm from unsafe medications and/or excessive doses, or excessive duration of treatment, while optimizing pain management strategies for all Veterans. Optimal treatment of chronic pain requires a coordinated multi-modality, interdisciplinary approach. Opioids are an important component of pain management but are rarely appropriate as first-line or sole treatment options. Excluded from this policy are patients receiving opioid therapy for treatment of cancer-related pain, and in end-of-life or palliative care situations. 3. DEFINITION: a. Chronic Non-Malignant Pain. In general, it is defined as any continuous pain lasting longer than (3) months. It may or may not have an identifiable organic cause and typically includes exacerbations and remissions. Treatment goals focus on improved quality of life and physical and psychosocial functioning. b. Breakthrough Pain. Transient exacerbation of pain that occurs in patients with otherwise stable baseline persistent pain. c. Chronic Opioid Use. Consistent use of a DEA schedule II or III opioid for greater than or equal to 90 calendar days. 4 GUIDANCE: a. Initial Patient Assessment 1) All opioid prescribers are advised to follow the VA/DOD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain provides practitioner guidance on initial patient assessment and determination of appropriateness of opioid therapy for chronic pain. If determination that 1

2 treatment is indicated, the treatment plan must be included as part of the documentation. 2) To make sure all key elements are included in the initial assessment, it is recommended that a standardized note template be utilized, Initial Assessment of Chronic Opioid Therapy. b. Opioid Agreement 1) A nationally standardized IMED consent for long-term opioid therapy for pain management must be completed on all patients on chronic opioid therapy. This requirement does not apply to patients enrolled in hospice, or patients receiving long-term opioids for cancer pain. All requirements for VHA Directive 1005 must be met. 2) A Clinical Reminder must be established to ensure this consent process is completed in all patients on chronic opioid therapy. This is a one-time clinical reminder. 3) Essential elements of this Directive include: a) Completing the informed consent process b) Providing the patient a copy of the standardized patient information guide titled "Taking Opioids responsibly for Your Safety and the Safety of Others" c) Reviewing and discussing the contents of the information guide with the patient. d) Developing and publishing a local policy and procedures consistent with the requirements of VHA Directive c. Follow-up Assessment a) All opioid prescribers are advised to follow the VA/DOD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain which provides practitioner guidance on follow-up assessment and appropriate assessment intervals. b) Assessments must be done every 1-6 months during the duration of maintenance therapy. c) It is recommended that a Clinical Reminder be established to ensure assessments are completed at a minimum of every 6 months. The Clinical Reminder should link to a standardized Opioid Therapy Assessment Note that contains the essential elements needed to assess patients on chronic opioid therapy. d. Urine Drug Screening (UDS) a) UDS is utilized to mitigate risk of opioid prescribing. b) VISN PLMS will provide comprehensive testing to include testing for semisynthetic and synthetic opioids, and confirmatory testing where needed. c) The frequency of UDS must be annually at a minimum, with more frequent testing based upon risk stratification. d) It is recommended that a Clinical Reminder be established to ensure UDSs are completed at a minimum of every 12 months and when initiating an opioid as therapy. e. Prescription Drug Monitoring Program (PDMP) 2

3 a) Please refer to VISN policy on State Prescription Drug Monitoring Program. b) PDMP's are designed to detect and prevent prescription drug abuse by identifying individuals who seek to obtain prescriptions for addictive medications from multiple providers. c) The PDMP should be reviewed prior to initiating chronic opioid therapy. d) The frequency of PDMP searches should occur at least initially and annually thereafter for patients prescribed chronic opioids. Patients at higher risk for opioid misuse should have more frequent PDMP monitoring. e) It is recommended that a Clinical Reminder be established to ensure PDMP searches are completed at a minimum of every 12 months. The CR will be linked to the standardized note title, State Prescription Drug Monitoring Program. This note includes the necessary components required to meet Privacy regulations when searching PDMP. f. Discontinuation of Chronic Opioids a) If a patient's chronic opioid medication(s) is discontinued, the reason for discontinuance must be documented in CPRS. b) If there is no documented support for continued use, the patient should be tapered off opioids and other treatment options should be explored. If appropriate, consults to Pain Management, Substance Abuse clinics, or other modalities should be considered. c) Patients who abrogate their Opiate Informed Consent should not be prescribed opiates and offered gradual dose reduction when clinically appropriate. d) If there is suspicion or evidence of current abuse of alcohol, opiates, benzodiazepines, or illegal drugs/substances, the provider should discontinue opioids and consult the Substance Abuse Treatment Clinic (SATC) for evaluation and further recommendations. e) If a provider has objective evidence of misuse, opioids are immediately tapered off or discontinued, considering the need for appropriate tapering as medically necessary. Other medically acceptable means of "detoxification" may be used if needed. f) For safety reasons in patients receiving chronic opioid therapy for nonmalignant pain, if UDS detects marijuana, opioid therapy will be tapered and discontinued if the patient elects to continue use of any form of marijuana and opioids concurrently. Marijuana use will be documented in CPRS under non-va medication. g. Opioid Prescribing Procedures a) Except in cases where there is documentation of collaboration between providers for the treatment of the patient's chronic pain (i.e. pain clinic), patients may only be prescribed opioids for their chronic pain by their designated or covering provider; a covering provider must be available at all times. b) Patients on chronic opioid therapy for non-malignant pain should not receive prescriptions in the ED, except as a 3-day emergency supply (if prescription 3

4 records indicate they have exhausted their supply). Exceptions for travelling can be considered on a case-by-case basis. Signage shall be posted in the ED waiting areas to inform patients of the opioid prescribing rules and their responsibilities. c) Prescriptions for opioids are limited to 30-day supplies or less. d) 2 8-day renewal cycles for schedule II opioid prescriptions are strongly encouraged to coordinate refill schedules, reduce out-of-meds requests and walk-in visits. e) Due to safety reasons, concurrent prescribing of opioids and benzodiazepines are strongly discouraged. There must be a strong clinical justification for combined use, where other alternatives can be considered. Facilities are encouraged to use processes such as a prior authorization or order check to educate providers and limit use of this combination. In particular, the combination of methadone and benzodiazepine is considered a critical drug interaction. f) The maximal morphine equivalent dose (MED) that can be prescribed by a Primary Care Provider will be 120 mg unless prescribed by a designated pain expert. Dose escalations above 120 morphine equivalents (whether existing, or new patient) will require second level review or prior authorization. Such concurrence may be at the facility's option, such as requiring consultation with appropriate specialties e.g. Step Two pain referral, Rehabilitation Medicine, Palliative Care, Rheumatology etc. g) Use of short-acting opioids in the treatment of chronic pain is discouraged. Sites should consider quantity limit of 120 short-acting opioids per 30-day supply (exception oncology, palliative care, pain clinic providers). 5. RESPONSIBILITY: a. Chief of staff is responsible for implementation and monitoring of compliance with this Network policy. b. Opioid prescribers are responsible for: 1) Following guidance described in this Network policy. 2) Addressing clinical reminders as recommended in this guidance c. Pharmacy service is responsible for: 1) Providing opioid utilization data for provider review. 2) Communicate to providers opioid prescriptions that appear to contribute to misuse, diversion, abuse, etc. and document concerns. d. ACOS/Education is responsible for providing training opportunities on pain management topics. 6, REFERENCES: a. Chou, R.; et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. Journal of Pain. Vol 10, Issue 2. Pages e22 (February 2009) b. Department of Veterans Affairs; Department of Defense. VA/DoD CLINICAL Practice Guideline for the Management of Opioid Therapy for Chronic Pain. March 2003, Version

5 c. Department of Veterans Affairs. Pain Management. VHA Directive October 28, d. Dunn K M, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ami Intern Med. 2010;152(2): e. Bohnert ASB, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF,Ilgen MA, Blow FC Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 305: f. Gomes T, Mamdani MM, Dhalla IA, et al. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med 2011; 171: g. Webster LR, Webster RM: Predicting aberrant behaviors in opioid-treated patients: Preliminary validation ofthe Opioid Risk Tool. Pain Med 6: , 2005 h. VHA Directive 1005, Informed Consent for Long-Term Opioid therapy for Pain, May 6, FOLLOW-UP RESPONSIBILITY: The Office of Network Director, Chief Medical Officer, is responsible for the contents of this Policy. 8. RESCISSION: None 9. RECERTIFICATION DATE: 10. AUTHORIZATION / APPROVING OFFICIAL: VA Desert Pacific Healthcare Network Date Distribution: Network 22 facilities 5